Measuring the practice of shared-decision making (OPTION12): An Investigation into Open-sourced Smaller LLMs (OS-sLLMs) for Better Privacy and Sustainability

Deploying large language models (LLMs) for decision support in emergency departments (EDs) faces two major challenges: privacy risks of transmitting patient data to closed-source commercial LLMs and the lack of systematic evaluation of fine-tuning strategies for locally deployable open-source small language models (SLMs). We benchmarked eight open-source SLMs using zero-shot prompting, prefix tuning, Low-Rank Adaptation (LoRA), and full fine-tuning on three ED tasks: triage level prediction, specialist referral recommendation, and diagnosis prediction. Using 2,083 MIMIC-IV-ED cases and Claude Haiku 4.5 and Claude Sonnet 4.5 as baselines, we found that LoRA fine-tuned open-source SLMs outperform commercial baselines on triage level prediction and specialist referral recommendation, while diagnosis prediction remains challenging for open-source SLMs. Confusion matrix analysis further shows that fine-tuned open-source SLMs can detect highest-severity patients missed by the commercial baselines. These results demonstrate that locally deployable SLMs can achieve clinically competitive performance for ED decision support.

Clinical decision support systems (CDSS) require scrutable, auditable pipelines that enable rigorous, reproducible validation. Yet current LLM-based CDSS remain largely opaque. Most "open" models are open-weight only, releasing parameters while withholding the data provenance, curation procedures, and generation pipelines that determine model behavior. Fully Open (FO) models, which expose the complete training stack end-to-end, do not currently exist in medicine. We introduce Fully Open Meditron, the first fully open pipeline for building LLM-CDSS, comprising a clinician-audited training corpus, a reproducible data construction and training framework, and a use-aligned evaluation protocol. The corpus unifies eight public medical QA datasets into a normalized conversational format and expands coverage with three clinician-vetted synthetic extensions: exam-style QA, guideline-grounded QA derived from 46,469 clinical practice guidelines, and clinical vignettes. The pipeline enforces system-wide decontamination, gold-label resampling of teacher generations, and end-to-end validation by a four-physician panel. We evaluate using an LLM-as-a-judge protocol over expert-written clinical vignettes, calibrated against 204 human raters. We apply the recipe to five FO base models (Apertus-70B/8B-Instruct, OLMo-2-32B-SFT, EuroLLM-22B/9B-Instruct). All MeditronFO variants are preferred over their bases. Apertus-70B-MeditronFO improves +6.6 points over its base (47.2% to 53.8%) on aggregate medical benchmarks, establishing a new FO SoTA. Gemma-3-27B-MeditronFO is preferred over MedGemma in 58.6% of LLM-as-a-judge comparisons and outperforms it on HealthBench (58% vs 55.9%). These results show that fully open pipelines can achieve state-of-the-art domain-specific performance without sacrificing auditability or reproducibility.

Large language models (LLMs) are widely used as judges for evaluating model outputs, but their high cost, latency, and opacity limit scalability. We introduce SLMJury, a framework for evaluating small language models (SLMs) as judges across two paradigms: closed-ended binary correctness and open-ended quality scoring. We benchmark 16 SLM judges (0.6B-14B parameters) from four model families across ten benchmarks: eight closed-ended tasks spanning mathematical, scientific, and general reasoning (N=64,824 judgments per configuration), plus SummEval and MT-Bench for summarization and conversational scoring. We formalize judging as a budget-conditioned function and study five dimensions. Four findings emerge. (1) The overthinking effect is domain-dependent: for most judges quick 10-token verdicts match or beat extended reasoning on mathematical judging (by 2-7% where they help), while reasoning wins on general tasks by up to 23%. (2) Domain generalization separates model families, with math-to-general accuracy gaps ranging from under 10% to nearly 40%. (3) Closed-ended and open-ended judging draw on different capabilities: the best binary judge (Phi-4) drops to rank 9 on MT-Bench, while reasoning-trained models invert this ordering. (4) Under the Reflect-Critique-Refine (RCR) debate protocol, multi-agent debate degrades accuracy across all tested configurations, whereas the top judges resist six adversarial personas with <=0.55% variance. Reliable automated evaluation does not require large proprietary models, yet no single SLM dominates. The leaderboard is available at https://anishh15.github.io/SLMJury/, and our framework code and pip package are publicly available at https://github.com/anishh15/SLMJury and https://pypi.org/project/slmjury/.